The Maynard Doctrine: Why are managers so dumb?

Health economist Professor Alan Maynard queries why healthcare managers appear unwilling or unable to learn from history and evidence.

Non-clinical managers and their medical colleagues appear to be dumb, as defined by their failure to learn from history and evidence. For this dumbness, they are highly paid and continue to manage the delivery of care characterised by variations in process, cost and outcomes that damages patients and taxpayers.

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First, let’s explore some evidence of these sins - and then let’s address the question of why they are so dumb.

Improving clinical accountability
In the late 1780s, there was a typhus outbreak in Manchester. The city fathers sought to deal with this by hiring more doctors. This precipitated a strike threat from existing practitioners, who feared the erosion of their income.

The commotion was resolved by hiring an eminent local doctor Thomas Percival to mediate between the warring parties. He wrote a nice book published in 1803 entitled ‘Medical Ethics or a code for Institutes and Precepts adapted to the Professional Conduct of Physicians and Surgeons’, with an appendix entitled ‘A Discourse on Medical Duties’.

Percival’s tome is in the Hippocratic tradition of improved self-governance and “physicians, heal thyselves”. Page 15-16 of his book contains some familiar wisdom:

“Hospital registers usually contain only a simple report of the number of patients admitted and discharged. By adopting a more comprehensive plan, they might be rendered subservient to medical science, and the benefit of mankind. The following sketch is offered, with deference to the gentlemen of the faculty. Let the register consist of three tables; the first specifying the number of patients admitted cured, relieved, discharge or dead; the second the several diseases of the patients with their events; the third the sexes, ages and occupations of the patients”.

Not only was Percival advocating outcome measurement, he also proposed that this data be used to compare performance and improve outcomes for patients:

“By adoption of the register … physicians and surgeons would obtain a clearer insight into the comparative success of their hospital and private practice; and would be incited to diligent investigation of the causes of such difference”.

The advocacy of the measurement of the comparative success of doctors in terms of outcomes continued later in the 19th century. The Lunacy Act of 1845 required all asylums to collect outcome data in terms of whether were dead, recovered, relieved and unrelieved. This legislation also incentivised data collection with fines of £2 for non-compliance.

Your local old psychiatric hospital may still have these outcome data for the period 1845-1948

Florence Nightingale (in ‘Some Notes on Hospitals’, appendix, 3rd edition) advocated outcome measurement in terms of whether patients were dead, relieved and unrelieved. Nightingale omitted the “recovered” criterion, and argued vigorous in favour of such measurement in London acute facilities - in particular with resistant clinical “leaders” for decades.

Ernest Codman was a Harvard trained surgeon whose operating rights were withdrawn by Massachusetts General Hospital in 1914. He was influenced by Percival and sought to measure “end points” with outcome measurement and follow-up of patients for a year. He set up his own hospital and made little money, as Mass. General produced no end point data and he did!

More recently, Buck, Devlin and Lunn initiated the Confidential Enquiry into Perioperative Deaths (Kings Fund & Nuffield 1985), a collaborative investigation by surgeons and anaesthetists. This showed familiar problems with routine data and the need for consultants to assess themselves regularly.

The tortoise and the scare
Progress in systematic performance measurement and management of consultants over 210 years makes the progress of a tortoise seem wonderfully rapid! Sir Bruce Keogh ( medical director of the NHS-CRB), having established comprehensive audit for cardiac surgeons in Britain and Ireland now hopes to have 10 surgical sub-specialties reviewing their performance this year.

But what about the rest of the medical profession? Audit exists in most specialties, but it may not always cover all practitioners. Furthermore, its processes and outcomes should be open so that managers and patients can see the relative risks they face in consuming healthcare.

It is time to stop tip-toeing around professional opposition to process and outcome audit and claims of clinical autonomy. As Percival argued 210 years ago, we need to incite “the diligent investigation of the causes of difference”. All power to Keogh as he persuades his clinical colleagues to be ethical!

Improving managerial accountability with evidence manure
Both clinical and non-clinical managers face the mushroom dilemma at present: they are showered with heaps of manure, and fail to flourish in the dark! Both groups are showered with advice which they lack the willingness and ability to access and use to improve patient care. This evidence manure has great potential to improve managerial practice and resource use - but this potential is poorly exploited. Evidence manure is essential for the growth and development of all NHS organisations!!

NHS-Centre for Reviews and Dissemination colleagues note that 75 randomised controlled trials are published every day and that PubMed, a source of research results, has 20 million citations in it. How can a mere NHS manager or clinician use such evidence bases?

It is not difficult! The government has invested in some high-quality synthesisers and communicators of evidence. The National Institute for Health and Clinical Excellence (NICE) not only provides mandatory technology appraisals, advisory clinical guidelines and public health evidence, it also provides advice on e.g. QIPP policies to adopt.

Sadly it appraises take-up of this information poorly and usage is poorly incentivised. Why don’t NHSCB regional offices require CCGs / providers to follow NICE-QIPP advice? Allowing PCTs and soon CCGs local discretion ensures failure to use evidence and depend on faith-based local wheezes!

You can lead a horse to water, but it still won’t be the way we drink water round here
NHS Evidence also offers advice on topics to build into annual QIPP contracts. This search engine provides evidence on health and social care. It links users to the Cochrane database and to the NHS Centre for Reviews and Dissemination.

Why don’t managers and clinicians use these organisations more thoroughly? It would assist their decision-making by confusing their investments with evidence; shattering the dominance of faith based policymaking in so many places!

The challenge for managers is not to resort to initiatives produced locally in isolation from the evidence base, but to use existing robust national evidence and apply it.

Why are managers so dumb?
Local autonomy and a preference for what is invented locally by amateurs in isolation from the evidence base dominates managerial decision-making. This creates replication of evidence-free ‘innovations’ which waste resources and, due to poor evaluation, rarely add to the evidence base.

What to do about the dumb?
Locally, chairs of NHS organisations should change job plans of senior managers to ensure they use national sources of evidence when designing QIPP programmes and reconfiguring their services.

All NHS organisations need to recruit expertise which ensures access to and use of the evidence base. Senior managers failing to exploit the potential of the evidence base should be penalised with pay cuts.

The spirit of “here is the information; please use it” (i.e. voluntarism) has failed. The NHSCB should incentivise the use of NICE / NHS Evidence / Cochrane evidence by ensuring that they and all regulatory agencies incorporated measures of evidence use in their appraisals. These valuable resources should not be ignored by clinical and non-clinical managers, but become routine parts of their work. This requires radical changes in career training (as argued in a previous blog).

Conclusions
The NHS problem is not that we do not know what to do in principle: it is that in practice, we fail to exploit the resources which are essential to do our job properly and ensure economy and excellence in patient care.

Ministers, managers and clinicians pay lip service to evidence-based decision-making but fail to practice what is preached by expensive information agencies.

For many centuries, the medical profession has known it needs to improve its governance to ensure patient protection through transparency and to increase productivity. The lack of progress in improving transparency and productivity is unethical and inefficient.

For decades it has been obvious that non clinical managerial skills are poor in terms of controlling resource allocation and improving patient care. All too often, the imperative is keeping the lid on expenditure, with too little regard to evidence as to whether that expenditure maximises improvements in the length and quality of patients’ lives

Managers, clinical and non-clinical, are often very talented, but they must demonstrate this better by being less myopic and focusing on the better use of often-excellent sources of evidence. The evidence manure which is showered on them is essential for the development of their organisations and the improvement of our health and social care. The maxim should be “ignore evidence at your peril and pay for deviance with your jobs!”